Depression in Primary Care
Depression affects around 2.3 million people in the UK at any one time and is the third most common reason for people going to see their GP. The diagnosis is not always straightforward: patients may be concerned about the stigma of mental illness (particularly in certain cultures) or they may somatise (experience their depression as a physical symptom such as generalised body pain). It is therefore extremely important that GPs are alert to the possibility of depression, particularly in high risk groups (see Figure 57).
History
As with other mental health problems, a good history is key to diagnosis and may also be therapeutic for the patient. Start with open questions and allow the patient time to explain how they are feeling in their own words. They may feel able to tell you everything straight away, or it may take a few consultations to establish rapport. They may cry and there may be long periods of silence. Allow the patient to direct the history, but ensure that you have covered the key points:
- Clarify what the patient means by ‘depressed’.
- Any obvious events that may have triggered these feelings?
- How long have they been feeling this way?
- Do they no longer enjoy things that they used to get pleasure from?
- Has sleep and/or appetite changed?
- Is concentration or memory affected?
- Do they feel fatigued, lethargic or ‘slowed down’?
- Any physical symptoms, such as sexual dysfunction, headaches, pain or digestive problems?
- Is the way that they feel impacting on their functioning at work or home?
- Who is at home with them? Are they aware?
- Ask specifically about self-harm or suicidal ideation.
- Any similar episodes before and how were they treated?
- Any other psychiatric illnesses or chronic physical illnesses?
- Clarify current medication, alcohol and illicit drug use.
- Any history of mental illness in the family?
Examination
While taking your history, you should be carrying out a mental state examination:
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